physician services performed by non
A GROWING RISK AREA FOR
Presented By William Mooney, CHC
Director of Compliance
Pediatrix Medical Group
Understanding the Issue
Key Billing Concepts
Medicaid Billing Guidelines
Billing Sheet for NPP’s
Implementation and Education
1. Understanding the Issue
Widespread misconception 1:
If a physician is considered the supervisor of the nonphysician practitioner (NPP) who performed the service,
co-signs the medical record, selects a procedure code
deemed reasonable for the service and allows his/her
name to be used to bill the claim, then the claim must be
correct, proper and meets all applicable laws and
regulations. The proof: the charge paid! But…
Widespread misconception 2:
An incorrect billing procedure is discovered with the NPP
billing. Going forward, billing for the service is stopped.
Consequently, the practice is now losing money it was
receiving. How can the lost money be replaced? There
must be some way to get paid (see #1).
A. Performing Provider
The clinician who performed the actual medical activity for
which payment is being sought by the practice:
Ö Non-physician Practitioners (NPP)
Ö Non-physician Auxiliary Personnel
Ö A Teaching Physician
Ö Locum tenens (substitute) physicians
B. Billing Provider
The provider, usually but not always a physician, who is
required to fulfill a defined role in relation to the performing
provider and to the service before payment may be sought. In
government programs, and most private payers, this is the
entity with ultimate responsibility for the “truth or falsity of
Set billing system to capture “Billing Provider” and “Performing
Non-physician Practitioners (NPP)
1. Includes NP, PA, CNM, CNS and CRNA.
2. Required licensing and certification by the state and
national certifying agencies.
3. Scopes of practice may include a defined level of
diagnosing and treatment.
4. Permitted to provide services independent of direct
(face-to-face) physician involvement with the patient.
5. Physician supervision in some form required in most
cases – ranging from written practice agreements to
6. Permitted, or required, by an increasing number of
payers to bill under their own name.
7. Generally receive a reduction from the physician fee
3. Key Billing Concepts
A. Physician Supervision
In the room - The supervising physician must be in the
room with the patient during the performance of the
On the premises - The supervising physician must be in
the facility/building/office and available to assist.
Available – The supervising physician must be available
and in reasonable communication, including
telecommunications with the provider during the service.
Administrative – Generally, the supervising physician
will have a written protocol, collaborative agreement or
other such document in place with the NPP. Personal
supervision during the service is not expected.
B. Incident to
All of the following requirements must be met in order
for services provided on an “incident to” basis to be
billable by the billing physician:
The billing physician must have seen the patient and
established a plan of care.
The “incident to” service must be performed by a qualified
The “incident to” service must be performed in an office
setting (virtually all), not hospital.
A supervising physician must be in the office and available
to assist at the time the “incident to” service is performed.
The “incident to” service is always billed under the billing
“Incident to” is a Medicare concept intended to allow the
physician in an office setting to bill for ancillary-type
services and some limited E/M services performed by an
NPP, thus freeing the physician to see other patients at
the same time. (See MCR IOM, Pub. 100-02, Chap 15,
Section 60 and Pub. 100-04, Chap 12, Section 30.6.4.)
A “consult” is not always a consultation.
Performance of a consultation service is limited to
practitioners who are permitted by scope of practice.
Billing may be further limited by payer rules.
Required activities that must be completed and
documented in the medical record are:
A written or verbal request from an appropriate source for an opinion
or expert advice
All components of an initial encounter E/M code completed as
defined in CPT-4
Written or verbal communication returned to the requestor
When the face-to-face time of the performing provider for counseling
and/or coordination of care as defined by CPT-4 is greater than 50%
of the total time of the encounter, then time is the controlling factor
to select the level of service to be billed. In these cases, (1) the
medical decision making component, (2) content of the counseling
and/or coordination of care and (3) actual time of the face-to-face
encounter or unit/floor activity must be documented as a minimum.
This “time” is ONLY the performing provider’s time.
CPT codes such as 99241-99245 and 99251-99255 should
be billed only after all of the conditions above have been
D. Medically Necessary
Sec. 1862 (a) Notwithstanding any other provision of this
title, no payment may be made under part A or part B for any
expenses incurred for items or services—
(1)(A) which are not reasonable and necessary for the
diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member…
SSA Sec. 1862 [42 U.S.C. 1395y]
Services or supplies that: are proper and needed for the
diagnosis or treatment of your medical condition, are
provided for the diagnosis, direct care, and treatment of your
medical condition, meet the standards of good medical
practice in the local area, and aren’t mainly for the
convenience of you or your doctor.
-CMS General Glossary
4. Medicaid Billing Guidelines
a) Advanced Practice Nurse (all specialties)
b) Physician Assistant
Factors not evaluated
a) Employment/contract in some form assumed
Who is permitted to bill for the service?
Qualifications and Enrollment
Physician Supervision and Documentation
Special Billing Instructions
MEDICAID BILLING GUIDELINES FOR NPP PROVIDER TYPE
State of ___________
Manual reviewed ___________
Billing in Name of
Billing in Name of
SUMMARY OF STATE MEDICAID BILLING GUIDELINES FOR THE
NEONATAL NURSE PRACTITIONER
FOR DOC TO BILL:
FOR NP TO BILL:
REVIEW AND SIGN
ON PREMISES; SIGN
5. Billing Sheet for NPP’s
>>TYPICAL BILLING WORKSHEET
REALLY COMPLIANT MEDICAL GROUP
Hospital Services Billing Worksheet
Patient name___________________ DOB___________ Acct #________
Provider name ______________________________________________
Referring physician __________________________________________
DATE OF SERVICE _____________
PROCEDURES: CIRCLE A CPT CODE
DIAGNOSES: CIRCLE ONE OR MORE
>>BILLING WORKSHEET FOR NPP’S
REALLY COMPLIANT MEDICAL GROUP
Hospital Services Billing Worksheet
Patient name___________________ DOB___________ Acct #_________
DATE OF SERVICE ____________________________________________
(1) Performing physician or NPP name _________________
(2) Supervising physician name ________________________
(3) Location of supervisor: __on premises __available __N/A
(4) Performing provider signature: _____________________
6. Implementation and
Write out state Medicaid billing guidelines
Revise/create NPP-specific billing sheets
Develop system edits for state rules
Who is billable?
CPT limited coverage?
Create training manual by user group
Education for the Physicians:
1. Physicians should complete, and review regularly,
collaborative agreements or protocols with the
NPP’s as required by state board and state
Medicaid payer regulations.
2. It is recommended that the practice apply state
Medicaid supervision guidelines for all services
performed by an NPP.
3. The practice should post a listing of times each
physician in the group will be serving as the
designated supervising physician.
4. The practice should implement procedures to
ensure the supervising physician countersigns
medical records (not always required, but
Training for the NPP’s:
1. Complete all fields on the Billing Worksheet for
all services personally performed.
2. Check that supervising physician name and
location are entered.
3. Locations are: (1) on the premises, (2) available
by phone, or (3) personal supervision does not
4. Sign off on medical record and billing sheet.
Training for the Billing Staff:
1. Review bill sheets for completeness. Return
incomplete sheets to the NPP.
2. Apply state Medicaid guidelines when billing for
Medicaid or Self Pay accounts.
3. What about Managed Care and Commercial
A. Apply specific NPP guidelines for Payer, if
B. Bill service under name of supervising
physician in all other cases.
The comments and opinions presented by the
speaker are those of the speaker and do not
represent the opinions of the Health Care
Compliance Association or Pediatrix Medical
Group, Inc. The speaker is not engaged in
rendering legal, accounting, or other professional
services. If legal advice or other expert assistance
is required, the services of a competent
professional person should be sought. Materials
referenced in the presentation or handed out by
the speaker may have copyright or other
limitations for use beyond personal review by the
©2006 by William J. Mooney